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Effective Date: 
7/2019

Documents

 

Instructions

Updated 7/2019

 

Purpose

Form 1046 is used by the local intellectual and developmental disability authority (LIDDA) Diversion coordinator to request an adult nursing facility (NF) transition slot for Home and Community-based Services (HCS).

 

When to Prepare

Form 1046 is completed by the LIDDA Diversion coordinator to request an adult NF transition slot for HCS once a person residing in an NF has expressed a desire to transition to the community from the NF.

 

Transmittal

LIDDA staff must scan the completed form, along with any supporting documentation, and send by secure email to HHSC at LIDDARequests@hhsc.state.tx.us. The subject line should read “Request for HCS Adult NF Transition Slot.”

 

Detailed Instructions

Date of Request — Enter the date the request is being submitted to HHSC.

LIDDA Name — Enter the name of the LIDDA requesting the adult NF transition slot for HCS.

Comp Code — Enter the requesting LIDDA’s designated component code.

LIDDA Diversion Coordinator — Enter the name of the Diversion coordinator submitting the request.

LIDDA Diversion Coordinator Email Address — Enter the email address of the LIDDA Diversion coordinator.

Area Code and Telephone No. — Enter the area code and telephone number for the LIDDA Diversion coordinator.

Person’s Name — Enter the first and last name of the person for whom the request is being made.

CARE ID — Enter the person’s Client Assignment and Registration (CARE) identification number.

Name of Legally Authorized Representative — Enter the first and last name of the legally authorized representative, if applicable. If not applicable, check the Not Applicable box.

Date of Nursing Facility (NF) Admission — Enter the date the person was admitted to the NF.

Medicaid Number — Enter the person’s Medicaid number for whom the request is being made.

Date of Birth — Enter the person’s date of birth.

Date of PASRR Evaluation (PE) — Enter the person’s date of the Preadmission Screening and Resident Review (PASRR) Evaluation.

By submitting this form to HHSC, the LIDDA attests that the request is for a person who meets the following criteria:

  • The person is at least 21 years of age;
  • The person currently resides in an NF;
  • The person has expressed a desire to live in a community setting; and
  • It is not within the first 30 days after the person’s admission, if the person was admitted to the NF for rehabilitative purposes.

Comments — Enter any relevant information. This is not a required field, but helpful in communicating with HHSC.

Diversion Coordinator Signature and Date — The Diversion coordinator signs the form and enters the date. The last section is for HHSC use only.

Date and time request is received — HHSC staff enters the date and time.

Reviewer Signature and Date — The reviewer signs the form and enters the date.